Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PHI FREE PSA

Facility

$25.80

Service Code	CPT 84154
Hospital Charge Code	900915519
Hospital Revenue Code	300
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$20.64
Rate for Payer: Cash Price	$25.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.64
Rate for Payer: Health Smart Auto/Commercial	$15.48
Rate for Payer: LLUH Dept of Risk Management WC	$14.19
Rate for Payer: Multiplan Commercial	$19.35

HC SOM PHI FREE PSA

Facility

$25.80

Service Code	CPT 84154
Hospital Charge Code	900915519
Hospital Revenue Code	300
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$20.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.48
Rate for Payer: Aetna of CA Government/Medicare	$15.48
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cash Price	$25.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.64
Rate for Payer: Health Smart Auto/Commercial	$15.48
Rate for Payer: Intervalley Health Plan Commercial	$18.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.48
Rate for Payer: LLUH Dept of Risk Management WC	$14.19
Rate for Payer: Multiplan Commercial	$19.35

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$25.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.46
Rate for Payer: Aetna of CA Government/Medicare	$14.46
Rate for Payer: Cash Price	$24.10
Rate for Payer: Cash Price	$24.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.28
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: Intervalley Health Plan Commercial	$25.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Commercial	$18.07

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$19.28
Rate for Payer: Cash Price	$24.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.28
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Commercial	$18.07

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185
Hospital Charge Code	900914176
Hospital Revenue Code	309
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$63.57
Rate for Payer: Cash Price	$79.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.57
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Commercial	$59.59

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185
Hospital Charge Code	900914176
Hospital Revenue Code	309
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$63.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.68
Rate for Payer: Aetna of CA Government/Medicare	$47.68
Rate for Payer: Cash Price	$79.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.57
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Commercial	$59.59

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184
Hospital Charge Code	900914173
Hospital Revenue Code	309
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$56.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.32
Rate for Payer: Aetna of CA Government/Medicare	$42.32
Rate for Payer: Cash Price	$70.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.43
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Commercial	$52.91

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184
Hospital Charge Code	900914173
Hospital Revenue Code	309
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$56.43
Rate for Payer: Cash Price	$70.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.43
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Commercial	$52.91

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420
Hospital Charge Code	900911325
Hospital Revenue Code	305
Min. Negotiated Rate	$6.53
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$6.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420
Hospital Charge Code	900911325
Hospital Revenue Code	305
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315
Hospital Charge Code	900913891
Hospital Revenue Code	309
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$207.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.56
Rate for Payer: Aetna of CA Government/Medicare	$153.56
Rate for Payer: Cash Price	$255.94
Rate for Payer: Cash Price	$255.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.75
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: Intervalley Health Plan Commercial	$207.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Commercial	$191.96

HC SOM PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315
Hospital Charge Code	900913891
Hospital Revenue Code	309
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$255.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.75
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Commercial	$191.96

HC SOM PNEUMOCYSTIS PCR

Facility

$112.00

Service Code	CPT 87798
Hospital Charge Code	900915467
Hospital Revenue Code	300
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$89.60
Rate for Payer: Cash Price	$112.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.60
Rate for Payer: Health Smart Auto/Commercial	$67.20
Rate for Payer: LLUH Dept of Risk Management WC	$61.60
Rate for Payer: Multiplan Commercial	$84.00

HC SOM PNEUMOCYSTIS PCR

Facility

$112.00

Service Code	CPT 87798
Hospital Charge Code	900915467
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$89.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.20
Rate for Payer: Aetna of CA Government/Medicare	$67.20
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.60
Rate for Payer: Health Smart Auto/Commercial	$67.20
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.20
Rate for Payer: LLUH Dept of Risk Management WC	$61.60
Rate for Payer: Multiplan Commercial	$84.00

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Intervalley Health Plan Commercial	$8.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$22.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.15
Rate for Payer: Aetna of CA Government/Medicare	$17.15
Rate for Payer: Cash Price	$28.59
Rate for Payer: Cash Price	$28.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.87
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: Intervalley Health Plan Commercial	$14.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Commercial	$21.44

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$22.87
Rate for Payer: Cash Price	$28.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.87
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Commercial	$21.44

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$13.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.85
Rate for Payer: Aetna of CA Government/Medicare	$9.85
Rate for Payer: Cash Price	$16.41
Rate for Payer: Cash Price	$16.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.13
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: Intervalley Health Plan Commercial	$8.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Commercial	$12.31

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$13.13
Rate for Payer: Cash Price	$16.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.13
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Commercial	$12.31

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$27.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Commercial	$20.33

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$27.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$27.11
Rate for Payer: Cash Price	$27.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Intervalley Health Plan Commercial	$27.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Commercial	$20.33

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$51.07
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Intervalley Health Plan Commercial	$51.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM PREGNENOLONE, SERUM

Facility

$25.00

Service Code	CPT 84140
Hospital Charge Code	900915512
Hospital Revenue Code	300
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$20.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

Know your out-of-pocket cost for care.

All Charges